AJR 2005; 184:415-417
© American Roentgen Ray Society
Temporary Occlusion of Two Hepatic Veins for Chemoembolization of Hepatocellular Carcinoma with Arteriohepatic Vein Shunts
Satoru Murata1,
Hiroyuki Tajima,
Yutaka Abe,
Tsuyoshi Fukunaga,
Ken Nakazawa,
Rabie Abdul Aziz Mohamad and
Tatsuo Kumazaki
1 All authors: Department of Radiology, Center for Advanced Medical Technology,
Nippon Medical School, 1-1-5 Sendagi, Bunkyou-ku, Tokyo, Japan.
Received October 21, 2003;
accepted after revision June 1, 2004.
Address correspondence to S. Murata
(murata_satoru/radiology{at}nms.ac.jp).
Introduction
Treatments for hepatocellular carcinoma have conventionally been divided
into curative and palliative. Recently, percutaneous ablation as palliative
treatment was shown to induce complete response in a high proportion of
patients with nonadvanced small hepatocellular carcinoma. In patients with
unresectable hepatocellular carcinoma, however, transcatheter arterial
chemoembolization is the most widely used palliative treatment.
Microscopic arteriovenous shunts usually are present in hepatocellular
carcinomas [1]. Hepatocellular
carcinoma tends to spread in the portal veins and, to a lesser extent, in the
hepatic vein [1]. Involvement
of intraportal and hepatic veins allows arteriovenous shunts to develop.
Development of hepatic arteriovenous shunts prevents effective embolization of
the tumor because anticancer drugs or mixtures of iodized oil and anticancer
drugs easily go through the shunts
[2]. Consequently, conventional
transcatheter arterial chemoembolization causes liver dysfunction in patients
with hepatocellular carcinoma with arterioportal venous shunts, because
embolization of the portal veins induces ischemia of nontumorous liver
parenchyma, or causes pulmonary embolism in patients with hepatocellular
carcinoma with arteriohepatic vein shunts
[3–5].
Therefore, a useful treatment for liver tumors with significant arteriovenous
shunts is needed. We report successful transcatheter arterial
chemoembolization using temporary occlusion of two hepatic veins for treatment
of a huge hepatocellular carcinoma with significant intratumoral
arteriohepatic vein shunts.
Subject and Methods
A 68-year-old man was admitted to our hospital for treatment of a liver
tumor. His medical history was significant for hepatitis C, and he had been
undergoing follow-up for 9 years. His 
-fetoprotein level was 542 ng/mL
(normal < 20 ng/mL).
A contrast-enhanced CT scan was obtained, and it revealed a 6-cm-diameter
hepatocellular carcinoma at the upper portion of the superoanterior segment
and bone metastases of the right ribs. The patient then underwent angiographic
examination for further evaluation. CT during arteriography showed a
hepatocellular carcinoma with an intratumoral arteriohepatic vein shunt and
revealed that contrast medium drained directly from the hepatocellular
carcinoma into the right hepatic vein during the early arterial phase
(Fig. 1A). For CT
arteriography, a total volume of 40 mL of diluted nonionic contrast material
(100 mg I/mL diluted with physiologic saline) was injected into the proper
hepatic artery at a rate of 2.0 mL/sec. CT arteriography was performed 5 sec
after the onset of injection (table speed, 7 mm/sec). Selective proper hepatic
arteriography showed the moderately hypervascular hepatocellular carcinoma
with an intratumoral hepatic vein shunt during the early arterial phase
(Fig. 1B).
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Fig. 1A. —68-year-old man with huge hepatocellular carcinoma with
intratumoral arteriohepatic vein anastomoses. CT scan obtained during
arteriography reveals 6-cm-diameter hepatocellular carcinoma (arrows)
at upper portion of superoanterior segment with intratumoral hepatic vein
shunts. Contrast medium is shown to drain directly from hepatocellular
carcinoma into right hepatic vein (arrowhead).
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Fig. 1B. —68-year-old man with huge hepatocellular carcinoma with
intratumoral arteriohepatic vein anastomoses. Celiac arteriograph shows
moderately hypervascular hepatocellular carcinoma with significant
intratumoral arteriohepatic vein shunt (arrow).
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For transcatheter arterial chemoembolization, we injected mixtures of
iodized oil (total volume = tumor diameter [cm] + 1 mL; Lipiodol UF, Nihon
Schering) and doxorubicin (40 mg) through a microcatheter (Rapid Transit,
Cordis) into the anterior segmental branch of the hepatic artery. After that
injection, particles of gelatin sponge (1 mm2) were injected. On
fluoroscopy, the accumulation of iodized oil in the hepatocellular carcinoma
was poor, and iodized oil went through the arteriohepatic shunt into the
inferior vena cava during the injection. Then, transcatheter arterial
chemoembolization was stopped, and a small amount of particles of gelatin
sponge was injected through the microcatheter. Proper hepatic arteriography
after embolization with gelatin sponge particles depicted an obstruction of
the anterior segmental branch of the hepatic artery.
CT was performed to evaluate the efficacy of transcatheter arterial
chemoembolization 3 weeks after treatment. It showed that the hepatocellular
carcinoma had progressed (8 cm in diameter). Therefore, we attempted a second
transcatheter arterial chemoembolization procedure with balloon occlusion of
the right hepatic vein as a draining vein. We punctured the right femoral vein
and inserted an 8-French sheath. The balloon catheter had a 6-French shaft and
20-mm-diameter balloon at the tip. We inserted it into the right hepatic vein
and inflated the balloon by hand using 4 mL of diluted nonionic contrast
material. Our method of confirmation of the right hepatic vein was that right
and middle hepatic venography was performed by hand injection using occlusion
of each hepatic vein with the patient in the right oblique position, and then
the right hepatic vein was confirmed. Selective proper hepatic arteriography
under balloon occlusion of the right hepatic vein, however, revealed the
middle hepatic vein as a draining vein in the early arterial phase, a finding
that angiography did not show without hepatic vein occlusion. Next, we
punctured the left femoral vein and inserted a balloon catheter for occlusion
of the middle hepatic vein. Transcatheter arterial chemoembolization was
performed with occlusion of the two hepatic veins
(Fig. 1C), and it achieved a
good accumulation of iodized oil in the hepatocellular carcinoma. At that same
time, we also performed superselective transcatheter arterial
chemoembolization for the bone metastases of the right ribs.
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Fig. 1C. —68-year-old man with huge hepatocellular carcinoma with
intratumoral arteriohepatic vein anastomoses. Selective proper hepatic
arteriograph with balloon occlusion of both right and middle hepatic veins
shows no intratumoral arteriohepatic vein shunts. Arrows indicate two
balloons.
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One month later, we tried to perform transcatheter arterial
chemoembolization again to treat residual hepatocellular carcinoma. Selective
proper hepatic arteriography revealed the absence of the intratumoral
arteriohepatic vein shunts (Fig.
1D), and transcatheter arterial chemoembolization was performed
without occlusion of the hepatic veins.
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Fig. 1D. —68-year-old man with huge hepatocellular carcinoma with
intratumoral arteriohepatic vein anastomoses. Selective proper hepatic
arteriograph 1 month after transcatheter arterial chemoembolization with
hepatic vein occlusion shows disappearance of intratumoral arteriohepatic vein
shunts.
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The patient was invited to come to our outpatient clinic for follow-up once
a month. CT of the abdomen was performed every month for 3 months and then
once every 3 months or when clinically indicated. When we identified regrowth
of the tumor, transcatheter arterial chemoembolization was performed again
considering the systemic conditions. After 1 year, conventional transcatheter
arterial chemoembolization was performed a fourth time. The patient was alive
21 months after the first transcatheter arterial chemoembolization with
hepatic venous occlusion.
Discussion
Development of hepatic arteriovenous shunts is one of the main impediments
for successful transcatheter arterial chemoembolization therapy because
anticancer drugs or mixtures of iodized oil and anticancer drugs easily go
through the shunts. In patients with a significant arteriovenous shunt,
transcatheter arterial chemoembolization sometimes causes liver dysfunction
because of extensive embolization of the portal veins or causes pulmonary
embolism, especially in patients with arteriohepatic vein shunts
[3–5].
Therefore, conventional transcatheter arterial chemoembolization is not
effective and is harmful for patients with these shunts.
Although radiofrequency ablation is a useful treatment for small liver
tumors, we could not perform radiofrequency ablation because our patient had a
huge hepatocellular carcinoma with significant intratumoral arteriohepatic
vein shunts. To overcome such a disadvantage, we tried to perform
transcatheter arterial chemoembolization of the feeding arteries under
occlusion of the right hepatic vein as a draining vein, which angiography and
CT revealed. However, selective proper hepatic arteriography under occlusion
of the right hepatic vein revealed that the middle hepatic vein was another
draining vein, a finding that angiography did not show without hepatic vein
occlusion. This phenomenon was not surprising because hepatic venovenous
anastomoses usually exist in the liver
[6–7]
and the middle hepatic vein played a role in draining blood into the systemic
circulation through the tumor and the right hepatic vein was occluded by a
balloon catheter. Therefore, transcatheter arterial chemoembolization was
performed under occlusion of the two hepatic veins: the right and middle
hepatic veins. Using this temporary-occlusion procedure, we obtained good
accumulation of iodized oil in the hepatocellular carcinoma. Surprisingly,
hepatic arteriography after transcatheter arterial chemoembolization showed
the absence of intratumoral arteriohepatic vein shunts. Consequently, we
performed conventional transcatheter arterial chemoembolization five times and
obtained good control of tumor growth. The reason for the disappearance of the
intratumoral arteriohepatic vein shunts was that enough embolization was
achieved not only of the tumor but also of portions of the intratumoral
arteriohepatic vein shunts by means of balloon occlusion of the two hepatic
veins that were the draining veins of the tumor.
In conclusion, we performed transcatheter arterial chemoembolization using
temporary occlusion of two hepatic veins for treatment of a patient with a
huge hepatocellular carcinoma with significant intratumoral arteriohepatic
vein shunts. Disappearance of the shunts and good tumor growth control were
achieved with this method, and it may be a useful therapy for patients with
liver tumors with significant intratumoral arteriohepatic vein shunts.
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Introduction
Subject and Methods
